• Temple EM

Revisiting the value of the FAST exam

Tell me if you’ve heard this one before: A young man gets wheeled into the trauma bay. He’s calm–doing his thing–probably texting–when the EMT or police officer reports that he’s been stabbed in the chest.

“In the chest?” you ask.

“In the chest,” she says. For emphasis she points. And sure enough, right in the center of his chest you see a small wound–not horrible looking, but a wound nonetheless.

You look at the patient. He looks up from his phone, then down at his chest. He shrugs and then goes back to texting.

The patient is then slid on to the gurney and the commotion starts. IV’s are placed. Lines are established. The monitor starts to buzz. The trauma senior arrives and asks what’s going on.

“He’s been stabbed in the chest,” you say.

“The chest?” she asks.

“The chest,” you reply and for emphasis you point to the chest. The trauma chief looks at the stab wound, then at the patient, who again shrugs his shoulders, before going back to texting.

“Alright, let’s roll him.”

You commence to role. One way. Then the other. Arms are pulled. Legs are lifted. No other stab wounds are appreciated. The primary and secondary surveys are complete. The patient is stable. Fluids are running. Things are humming right along. Someone starts the FAST. You begin to whistle.     

“What’s that?” the FAST person asks.

You turn. Hmmm? The probe is on heart. The heart is on the screen. And just above the heart you see some fluid.

“That looks like fluid,” you say.

“Fluid?” the trauma senior asks.

“Fluid.”

The trauma senior looks at the probe that’s on the heart and the heart that’s on the screen and screen that shows the fluid. “That’s blood.”

Everyone looks back at the chest wound. Then up at the patient, who no longer shrugs and is no longer texting.

From the back of the room you hear the trauma attending: “Shit.”

And that’s how the story goes. The patient is then whisked away to the OR, where the life threatening bleed is stopped. He lives. He goes home. Another win for the FAST exam. Somewhere, the ultrasound fellow leaps for joy. Hurray.

Such a story makes you wonder, what the hell did they do before ultrasound? Would this person have gone to CT? Would the bleed have been diagnosed? Would the patient have died?  

Difficult as it is to believe, not too long ago, the utility of the FAST exam remained in doubt. Some thought it was pointless. A waste of time. Not nearly as good as what doctors were already doing. Plenty of people thought it was helpful, but it wasn’t until a crucial randomized control trial that practitioners fully appreciated the importance of bedside ultrasonography in the diagnosis of life threatening bleeds.

Enter the PLUS for Trauma in the ED study (or officially the Randomized Controlled Clinical Trial of Point-of-Care, Limited Ultrasonography for Trauma in the Emergency Department: The First Sonography Outcomes Assessment Program Trial). This paper aimed to determine if ultrasound reduced the time it took for a trauma patient to go from the ED to the OR. Of the 260-ish patients that were enrolled–135 received a bedside ultrasound and 127 did not. Overall, the patients that received an ultrasound, spent less time in the hospital, underwent fewer CT’s and–as you can probably guess–saw a reduction in total hospital costs.

But the big spotlight of this study was the ED to OR time. The benefit that so many ultrasound evangelists loved to preach, was that it could reduce unnecessary tests in the trauma bay and subsequently save lives. But did this really happen? Well, according to the numbers in the this study, patients who did NOT receive an ultrasound took more than 90 minutes longer to make it to the OR than those who did receive an ultrasound. 109 minutes to be exact (57 minutes vs 166). Let that percolate for a second. 109 minutes is a long time. Longer than a regulation soccer match. Longer than the first spacewalk. Nearly as long as the Patrick Swayze cinematic jewel, Road House.

Think what 109 minutes would have meant to our patient above. What would have happened if we took all that time waiting around trying to figure out what to do with him, instead of rushing him to the OR? I’m guessing the outcome would not have been as favorable. He probably would have died–never to text again. That is crazy. Now to be fair, the study did not look at mortality, specifically, so it may be presumptuous to proclaim more people are alive than dead because of the FAST exam, but it can’t be that far off.

Really, the point is to demonstrate that many of the procedures and tests we sometimes take for granted were not started all of a sudden–there wasn’t some universal realization when everyone came around to using things like apneic oxygenation or even antibiotics. This stuff had to be studied and restudied and then slowly over time, practitioners began to change their practice habits. Interesting to think about, even more so, when you go back and consider the studies that proved their value.

#FAST #Trauma #Ultrasound

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